General Consent for Care and Treatment

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and any recommended medical, surgical, or diagnostic care so that you may decide whether to undergo it after learning the associated risks, benefits, and alternatives. At this point in your care, no specific treatment plan has been recommended. This form gives Withings Medical Group PA your permission to perform the evaluation reasonably necessary to identify appropriate care for any condition(s) you may have.

1. Consent to Care and Treatment

I voluntarily consent to, and request that, the physicians, advanced practice providers (nurse practitioners, physician assistants, and clinical nurse specialists), nurses, and other health care professionals of Withings Medical Group, together with those they designate, provide the routine and necessary medical examinations, testing, and treatment they consider appropriate for the condition(s) for which I am seeking care. I understand this may include routine diagnostic procedures such as laboratory tests, imaging, and other non-invasive tests.

2. Additional Consent for Certain Procedures

I understand that if invasive, interventional, or higher-risk tests or procedures are recommended, I will be asked to review and sign a separate, procedure-specific informed consent before that test or procedure is performed, describing its nature, material risks, benefits, and reasonable alternatives.

3. Continuing Nature; Right to Revoke

I intend this consent to be continuing in nature and to remain in effect for my ongoing care at Withings Medical Group and at any affiliated professional entity of Withings Medical Group, even after a diagnosis has been made and treatment recommended. This consent remains fully effective until I revoke it in writing. I understand that I may discontinue services or withdraw my consent at any time.

4. Information, Questions, and Voluntary Consent

I have the right to discuss my care — including the purpose, potential risks, benefits, and alternatives of any recommended test or treatment — with my provider, and to have my questions answered before I decide. My consent is given freely and voluntarily. I understand that I will not lose any rights or benefits, and will not receive a lesser standard of care, if I decline any recommended test or treatment, and that I have the right to refuse care.

5. Telehealth / Virtual Care

I understand that some care may be provided through telehealth (virtual care) using technologies such as video conferencing or telephone; that telehealth has potential benefits as well as risks (including limits on physical examination and rare risks of technical interruption or of an unintended disclosure of health information); that I may choose or request in-person care instead; and that I may refuse or discontinue telehealth services at any time.

6. Practice of Medicine; No Guarantees

I understand that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me about the results of any examination, test, or treatment.

7. Trainees and Teaching Activities

If Withings Medical Group participates in the education of health-professional students, residents, or fellows, I understand that such individuals may take part in my care under the supervision of a licensed provider. I am under no obligation to participate in any activity whose primary purpose is educational, and my personal wishes will control the extent of my participation.

8. Disclosure for Payment and Continuity of Care; Assignment of Benefits

I authorize Withings Medical Group to use and disclose information from my medical record as reasonably necessary to obtain payment for services provided to me and to coordinate and provide continuity of my care, in accordance with applicable law and Withings Medical Group's Notice of Privacy Practices. I request that payment of authorized insurance benefits be made directly to Withings Medical Group, and I authorize the release of information needed to process such claims.

9. Agreement by a Personal Representative

If I am agreeing on behalf of the patient, I certify that I am the patient's legal guardian, health care agent, or other personal representative authorized under applicable law to consent to the patient's care, and that I am agreeing in that capacity.